New Coastal Patient Request Form If you are human, leave this field blank.New Patient Request Contact FormPlease complete all of the fields below. A Coastal Medical representative will contact you regarding your request by text message within 3 business days.First Name *Last Name *Date of Birth *Cell Phone Number *Please give us your cell phone number and a member of our team will text you within three business days to arrange a time to register you.Contact Email *Street AddressCityStateZip CodePreferred Time of Day for ContactPlease let us know what time of day is best for us to reach you.MorningAfternoonPreferred Coastal OfficeThe following Coastal Medical offices are currently accepting new patients. Please let us know which office you would prefer to join:No PreferenceCoastal Hillside Family MedicineCoastal Narragansett Family MedicineCoastal NewportCoastal WakefieldSecondary Coastal Office PreferenceThe following Coastal Medical offices are currently accepting new patients. Please let us know your second choice for which office you would prefer to join:No PreferenceCoastal Hillside Family MedicineCoastal Narragansett Family MedicineCoastal NewportCoastal WakefieldAdditional Comments:Is there anything else you would like us to know?Thank you for submitting your request to become a Coastal Medical patient. A member of our team will reach out to you via text within the next 3 business days . We look forward to caring for you. Submit